Reporting Form Questions
| Questions | Answer Format |
|---|---|
| Anonymous report form | |
| Indicate the role you were performing when you discovered the event | Check box; 6 choices |
| Type of practice | Check box; 4 choices |
| Describe the event you wish to report | Free text |
| In your opinion, could this event have been prevented? | Yes or no, plus free text |
| In your opinion, was (were) the patient(s) harmed as a result of this event? | Yes or no, plus free text |
| In your opinion, does (do) the patient(s) know about this event? | Yes or no, plus free text |
| Approximately how often do you think events like the one you are reporting occur in your practice? | Check box; 3 choices |
| Does this event involve just 1 patient? If YES… | Yes or no |
| Enter the patient’s age | Number |
| What is the patient’s sex? | Male/Female |
| Does the patient consider himself or herself to be Hispanic or Latino? | Yes or no |
| Please check the racial group(s) you believe the patient would want to be associated with | Check box(es); 6 choices |
| Confidential report form | |
| Your name | Free text |
| Telephone number where you can be reached | Telephone number |
| Indicate the best time to call | Check box; 2 choices |
| Briefly describe the event you wish to report | Free text |